Therapist Form

10

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Bio-Medical Instruments Inc.2387 East Eight Mile Road

Warren, MI 480!-248"

#hone$ %8"-7%"-%070 &a'$ %8"-7%"-8!

Public Listing Information

 Title ( Re)uired &ields

First Name

Middle

Last

Company Name

Address

Adress 2

City

State

Zip

Business Phone

Fax

Email

Contact Methods Phone Email Fax

e!site

Practicin" Since

A#era"e cost per session $

Accept %nsurance&  'es No

%ntroduction Para"raph(

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Private Information (if different from public listing)

 Title

First Name

Middle

Last

Address

Adress 2

City

State

Zip

Business Phone

Fax

Email

MA)* ALL T+AT APPL' %T+ AN ,(

Academic LicensingBachelor o- Science in Education Certi.ed Clini

Bachelor o- Science in Nursin" Clinical Psych0octor o- Chiropractics Clinical Social

0octor o- 0ental Sur"ery Family and C

0octor o- Education Licensed Clini

0octor o- Medicine Licensed Clini

0octor o- 1ptometry Licensed ra

0octor o- 1steopathy Licensed %nde

0octor o- Philosophy Licensed Marr

0octor o- Psycholo"y 3Ph04 Licensed Marr

0octor o- Psycholo"y 3Psy04 Licensed Marr

0octor o- Science Licensed Men0octor o- Social or/ Licensed Men

Master o- Arts Licensed Pro-

Master o- Counselin" Licensed Psyc

Master o- Education Licensed Psyc

Master o- Science Licensed Sch

Master o- Science in Nursin" Licensed Soci

Master o- Science in Social or/ Marria"e and

Master o- Social Science Marria"e5 Fa

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Master o- Social or/ Psycholo"ical

Phd Candidate )e"istered %n

)e"istered Nurse Social or/er

A

Certication AAP

Academy o- Clinical Social or/ers Ame

Ad#anced Clinical Practitioner BC%

American Association -or Marria"e and Family Therapy BC%

American Association o- Pro-essional +ypnotherapists Clini

American Board o- Examiners in Clinical Social or/ Edu

American Board o- Family Psycholo"y %n +

American Board o- Medical Psychotherapy %SN

American Board o- Psycholo"ical +ypnosis )es

BC%A Certi.ed in Bio-eed!ac/

BC%A Certi.ed in Neuro-eed!ac/

BC%A6Certi.ed in Pel#ic Muscle 0ys-unction Bio-eed!ac/

Board Certi.ed 0iplomate in Clinical Social or/

Board Certi.ed in Child and Adolescent Psycholo"y

Board Certi.ed in Clinical Social or/

Certi.ed Alcohol and 0ru" Counselor

Certi.ed Clinical Mental +ealth Counselor

Certi.ed Family Nurse Practitioner

Certi.ed %ndependent Social or/er

Certi.ed Marria"e and Family Therapist

Clinical Specialist in Adult Psychiatric and Mental +ealth Nursin"

0iplomate5 American Academy o- Beha#ioral Medicine

0iplomate5 American Board o- Psychiatry and Neurolo"y

0iplomate5 %nternational Academy o- Beha#ioral Medicine5 Counselin" and Psycholo"y

0iplomate5 Neuropsychiatry

National Academy o- Mental +ealth Counselors

National Board o- Certi.ed Counselors

National Certi.ed Counselor

National )e"ister o- +ealth Ser#ices Pro#iders in Psycholo"y

7EE Technician

7EE60iplomate

)e"istered +ealth Care Pro#ider

ModalitiesEC

EE

EM

Er"onomics

S)

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+eart )ate

+eart )ate 8aria!ility

+E

%ncontinence

1ximetry

7ee"

)espirationStimulation

 Temperature

Specialties %rrita!le Bo9e

Addiction *nee Pain

An"er Mana"ement Lo9er Bac/ P

Anxiety Mood 0isorde

Arthritis Myo-ascial Pai

Asper"ers Neuromuscul

Asthma Pain Mana"eAttention 0e.cit 0isorder:+yperacti#ity 0isorder Par/inson;s a

Autistic Spectrum 0isorders Pea/ Per-orm

Breathin" Pro!lems Phantom Lim

Chest pain Post Traumati

Chronic 0isease Mana"ement Posture )elat

Chronic Pain 7EE Assess

Closed +ead %n=ury )aynaud;s Sy

Conduct and Attachment 0isorders )eha!

Constipation Sleep 0isorde

0epression Smo/in" Ces0e#elopmental 0isorders Spinal Cord %n

0yspha"ia Stress Mana"

Epilepsy and Sei>ure Stress Mana"

Fecal %ncontinence Stump Pain

Fi!romyal"ia Su!stance A!

eriatric Temporoman

+eadaches Tinnitus

+ypertension Traumatic Bra

+yper#entilation ?rinary %ncon

%nterstitial Cystitis

Acceptance

% a"ree to allo9 Bio6medical %nstruments5 %nc@ to use the a!o#e in-ormation -or pu!lishin" ithe in-ormation a!o#e is true and accurate to the !est o- my /no9led"e@ Bio6medical %nstrincorrect or inaccurate in-ormation@ Please chec/ the !ox !elo9@ Than/ you@

 

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% a#e rea t e acceptance an a"ree@

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(

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Email the -orm alon" 9ith a lar"e ima"e o- yoursel-5your lo"o5 your practice or your sta to !rian!io6medical@com

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al Social or/er

lo"istor/er

ild Counselor

cal Psycholo"ist

cal Social or/er

uate Social or/er

pendent Clinical Social or/er

ia"e and Family Counselor

ia"e and Family Therapist

ia"e5 Family and Child Counselor

al +ealth Counseloral +ealth Ser#ices

ssional Counselor

holo"ical Associate

holo"ical Examiner

ol Psycholo"ist

l or/er

Family Counselor

  ily and Child Therapist

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 Associate

ependent Social or/er

liations

 Mem!er

rican Nursin" Association

 Certi.ed

Mentor

cal Super#ision 3remote trainin"4

ator

  use Clinical Super#ision

 Mem!er

archer

Equipment UsedAlpha Stim

Brainmaster

BrainDuiry

BrainTrain

Cy"net

0eymed

+eartmath

%8A

  <

LENS

Mind Ali#e

Mitsar

Neuro"uide

Nexus

S*%L

 Thou"ht Technolo"y

 T18A

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l Syndrome

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rs

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ent  d Mo#ement 0isorders

nce < Sports Applications

Pain

 Stress 0isorder

d Pain

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